Staying Active with Nature s Edge 2014 REGISTRATION FORM To be completed by the participant s parent/legal guardian

Transcription

1 ¾ Avenue Rice Lake, WI phone fax Staying Active with Nature s Edge 2014 REGISTRATION FORM To be completed by the participant s parent/legal guardian GENERAL INFORMATION Participant s Last Name: First Name: Date of Birth: Age M F BMI (see attached form) Address: City: State: Zip: Home Phone: Alternative Phone: Parent/Legal Guardian: Address (if different from above): City: State: Zip: Home Phone: Work Phone: Alternative Phone: Secure Address: How did you hear about Staying Active with Nature s Edge? THERAPY HISTORY Is the participant currently receiving any therapy services (physical, occupational, or speech therapy services) at any location (school, private clinic, county, etc.)? Yes No If yes please tell us where and who the therapist is: Has the participant had therapy (physical, occupational, or speech therapy) in the past? Yes No If yes, please tell us where, when, and who the therapist(s) was:

2 HEALTH HISTORY Please indicate current or past problems in the following areas: Yes No Comments Vision Hearing Sensation Communication Heart Breathing Digestion Elimination Circulation Emotional Behavioral Pain Bone/Joint Muscular Thinking/Cognition Allergies What medications is the participant currently taking, including over-the-counter medications? Describe the participant s abilities/difficulties in the following areas, including assistance required or equipment needed: FUNCTION (mobility skills such as transfers, walking, wheelchair use, driving/bus riding) ACTIVITY LEVEL (endurance climbing stairs, estimated length of time participant can exercise, ability to play during entire recess time, etc.)?

3 SOCIAL (i.e., school, including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.) GOALS (Why are you applying for participation? What would you like to accomplish?) PARTICIPATION AGREEMENT I, (Parent s/guardian s Name), hereby agree that I will attend all Staying Active with Nature s Edge sessions with (participant s name). Signature of Parent or Legal Guardian Date

4 ¾ Avenue Rice Lake, WI phone fax RELEASE FORMS REGISTRATION AND GENERAL RELEASE FORM I, (Parent s/guardian's Name), hereby apply for participation in Staying Active with Nature s Edge on behalf of (participant s name). I acknowledge the risks and the potential for risks of the program s use of animals and outdoor and indoor equipment. However, I feel that the possible benefits are greater than the risks assumed. I hereby forever release, discharge, and hold free and harmless, for myself, my heirs and assigns, executors or administrators, all claims for damages against Nature's Edge Therapy Center, Inc., its therapists, instructors, aides, volunteers and /or employees, and the Payne Ranch, of any and all injuries and /or losses the participant, participant s family or guests may sustain while participating in Staying Active with Nature s Edge. Signature of Parent or Legal Guardian Date PHOTO RELEASE I consent to and authorize the use and reproduction by Nature's Edge Therapy Center, Inc. of any and all photographs and any other audiovisual materials taken of the participant, participant s family, or guests while in the Staying Active with Nature s Edge program for use in promotional materials, educational activities, exhibitions, or for any other use for the benefit of Nature s Edge Therapy Center, Inc. Signature of Parent or Legal Guardian Date DAMAGE AGREEMENT I, (Parent s/guardian s Name), hereby agree that I will be responsible for seeing that any children, guests, or animals brought by me on the premises of Nature s Edge Therapy Center, Inc. are properly supervised at all times while on such premises. I further agree that I will be liable for any damage to the property of Nature s Edge Therapy Center, Inc. or the Payne family, while on the premises of Nature s Edge Therapy Center, Inc., or in the Payne home, and/or for any loss of use of such property resulting from any such damage, caused by my negligence or that of any child, guest, or animal brought on such premises by me. I further agree to pay for any necessary repairs or to reimburse Nature s Edge Therapy Center, Inc. and/or the Payne family for the reasonable cost of repair, replacement, and/or loss of use of such property pending repair or replacement. Signature of Parent or Legal Guardian Date

5 ¾ Avenue Rice Lake, WI phone fax Participant s Name: AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT In the event of an emergency, contact: Name: Relationship: Phone: Name: Relationship: Phone: Consent Plan In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services from, or while being on the property of, Nature's Edge Therapy Center, Inc., and the above cannot be reached, I authorize Nature's Edge Therapy Center, Inc. to: Secure and retain medical treatment and transportation if needed. Release the above-named participant s records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes X-rays, surgery, hospitalization, medication, and any treatment procedure deemed "life-saving" by the physician. This provision will only be invoked if the person(s) above is unable to be reached. Consent Signature: Parent or Legal Guardian Date: Non-Consent Plan I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services from, or while being the property of, Nature's Edge Therapy Center, Inc. In the event emergency treatment aid is required, I wish the following procedures to take place: Non-Consent Signature: Parent or Legal Guardian Date: A COPY OF THE COMPLETED PARTICIPANT HISTORY SHOULD BE ATTACHED TO THIS FORM.

6 ¾ Avenue Rice Lake, WI phone fax PARTICIPANT INTEREST SURVEY Name: Age: School you attend: Grade Level: What are your hobbies? What activities are you most interested in participating in? What is your favorite animal? What, if any, previous experiences have you had with large and/or small animals? What, if any, previous experiences have you had with exercise equipment (indoor or outdoor)?

7 Staying Active with Nature s Edge BMI Calculation It is important for the Staying Active with Nature s Edge group that accurate and current height and weight measurements are given to calculate true Body Mass Index (BMI). Priority in registration will be given to children who are obese or overweight based on their BMI. BMI is used as an indicator of body fatness. If a healthcare provider has recently taken height and weight measurements for your child, you may submit them with the date they were taken. If you have not recently visited a healthcare professional, please see the How To measurement instructions below to complete accurate measurements at home. Nature s Edge will then calculate your child s BMI. You may also submit a written document from your healthcare provider if your child has been diagnosed as obese or overweight. You MUST submit either this completed form or a written diagnosis from your healthcare provider in order for your child to participate in Staying Active with Nature s Edge. Child s Name: Date of Birth / / Gender (M/F) Measurements Weight (to the nearest ¼ or.25 pound) lbs. Height (to the nearest 1/8 inch) in. Date Measured / /2014 How To Measure Height At Home PREPARE: Remove child s shoes, large/bulky clothing, and flatten hair/remove accessories. EQUIPMENT: Tape measure, flat book, pencil MEASURING SURFACE: Do NOT measure on carpeted flooring or flooring with molding that sticks out on the bottom.

8 POSITION: Feet together flat on floor against the wall. Straight legs Arms at sides Level shoulders Look straight ahead with a line of sight that is parallel with the floor Head, shoulder, buttocks, and heels should be touching the wall MEASURING: Place a flat headpiece (book) on the crown of the head so it forms a right angle with the wall (see picture). Measurer's eyes should be the same level as the headpiece (see picture) Place a mark on the wall at the bottom of the headpiece. Measure from the floor to your mark for the height measurement. Accurately record the height to the nearest 1/8th inch. How To Measure Weight At Home EQUIPMENT: Digital scale that measures to the nearest ¼ (.25) pound (avoid spring-loaded bathroom scales) MEASURING SURFACE: Scale should be on firm flooring (wood/tile). No carpet. PREPARE: Remove shoes and heavy clothing (sweaters, sweatshirts, etc.) MEASURING: Stand on the scale with both feet in the center. Record weight to the nearest ¼ (.25) pound